2011-1

Abdomen (AB) International Clinical Verification (CV) Form
(Only to be used by individuals not residing in the U.S or Canada.)
Applicants Name: _____________________________________________________________ and ARDMS Number : _____________________________________ All of the Clinical Verification Forms are available online by visiting ARDMS.org/CV. You must use the correct form for each applied for specialty examination. Please submit this ORIGINAL form for receipt within 21 days of applying for the Abdomen (AB) Specialty examination. To be eligible to sit for the AB specialty examination, the applicant must be able to demonstrate the following minimum core clinical skills necessary to establish eligibility for ARDMS examinations. Demonstration of minimum core clinical skills means that the sponsor directly observed the applicant perform the minimum core clinical skills independently and effectively. For purposes of satisfying this requirement applicants must be evaluated while scanning actual patients. Simulation is not acceptable for this assessment. Applicants are responsible for meeting the requirements at the time of application.

Clinical Verification

Sponsoring Sonographer/Reporting Physician Initials

(Sign for Each Section)

1. Interact appropriately with the patient, physicians and staff. 2. Identify the pertinent clinical questions and the goal of the examination. 3. Recognize significant clinical information and historical facts from the patient and the medical records, which may impact the diagnostic examination. 4. Review data from current and previous examinations to produce a written/oral summary of technical findings, including relevant interval changes, for the reporting physicians reference. 5. Select the correct transducer type and frequency for examination(s) being performed. 6. Adjust instrument controls including examination presets, scale size, focal zone(s), overall gain, time gain compensation, and frame rate to optimize image quality. 7. Demonstrate knowledge and understanding of Doppler ultrasound principles, spectral analysis, and color flow imaging relevant to and in the AB specialty. 8. Demonstrate knowledge and understanding of anatomy, physiology, pathology and pathophysiology relevant to and in the AB specialty. 9. Demonstrate the ability to perform sonographic examinations of the appropriate organs and areas of interest according to professional and employing institution protocols relevant to and in the AB specialty. 10. Recognize, identify and document the abnormal sonographic patterns of disease processes, pathology, and pathophysiology of the organs and areas of interest. Modify the scanning protocol based on the sonographic findings and the differential diagnosis relevant to and in the AB specialty. 11. Perform related measurements from sonographic images or data. 12. Utilize appropriate examination recording devices to obtain pertinent documentation of examination findings. Note: This form is valid for one year from the signature date of the Sponsoring Sonographer or Reporting Physician. The Sponsoring Sonographer must be an Active status RDMS (AB) Registrant. A Reporting Physician must be a medical doctor specifically trained to interpret Abdomen ultrasound studies and who has directly observed the applicant demonstrate the minimum core clinical skills listed on this form. CV forms cannot be signed by a relative of the applicant. This form must contain original (signed) initials and signatures. Original initials must be included for each numbered skill, above. Facsimiles and photocopies of signatures, initials or the document are not acceptable. ARDMS conducts random audits of some applications for examination. Applicants who are audited will be required to submit additional documentation to substantiate eligibility. Sponsoring Sonographer Verification Statement/Reporting Physician Statement My signature verifies that I am currently ARDMS registered in the Abdomen Specialty or that I am a Reporting Physician practicing in the field of Abdomen ultrasound. I certify that I have directly observed (name of applicant) __________________ successfully demonstrate the minimum core clinical skills as listed on this Clinical Verification Form for the Abdomen Specialty. I understand that submitting false documentation to ARDMS is a violation of ARDMS rules and may result in sanctions including but not limited to revocation of my certification and eligibility for registration in all categories, including those already held. My signature below verifies that I have read this form in its entirety and completed it truthfully. I, ____________________________, Sponsoring Sonographer or Reporting Physician, of (name of applicant) ___________________________, certify that the applicant named hereon has successfully demonstrated the minimum core clinical skills necessary to establish acceptance for the ARDMS Abdomen Specialty Examination. Signature of Sponsoring Sonographer including ARDMS number or Signature of Reporting Physician including Medical License Number: (Please sign below) _____________________________________________________________________________________________________________________________________ Name (Please Print ): ____________________________________________________________________________________________________________________ Date (MM/DD/YYYY) :______________________________________________________________ Phone #:____________________________________________________________ E-mail Address: _______________________________________________________________________________________________________________________

Please return this form within 21 days of Application Submission to:
51 Monroe Street, Plaza East 1, Rockville, Maryland 20850-2400 t 301.738.8401 t 800.541.9754